A pox on the critics – Diagnosis: Sour grapes

Michael Arnold Glueck, M.D., is a multiple award-winning writer who comments on medical-legal issues. Robert J. Cihak, M.D., is a former president of the Association of American Physicians and Surgeons. Both doctors are Harvard-trained diagnostic radiologists.

Although al-Qaida candidly bangs the drums more rapidly with the threat of a bio-weapons attack against the United States and Israel, many public officials insist on sticking their heads in the sand one more time. Fortunately, not the president.

Last December, the Bush administration decided to proceed with national voluntary smallpox immunization – a policy we, The Medicine Men, had been advocating for some time.

Since then, the decision has drawn its share of criticism from the national public-health community. Some seems to fit the predictable category of sour grapes, complaints that the usual experts – among them, experts Bill Clinton hired – were insufficiently “consulted.” But some of the carping leads, albeit unintentionally, to an opportunity for the nation to take a hard look at our vaccination practices as a whole. And some reveals that, when you’re dealing with bureaucracy, the rule is: First, protect thy turf.

In a Dec. 29 Los Angeles Times commentary, Linda Rosenstock, M.D., dean of the UCLA School of Public Health and director of the National Institute for Occupational Safety and Health in the Clinton administration, wrote, somewhat sourly:

It may come as a surprise to some that we don’t make health policy in this country based on portentous warnings from behind closed doors. Making such sweeping decisions as President Bush has done on smallpox vaccination – keeping the public and experts in the dark – is simply indefensible.

Actually, it’s quite defensible. We medical and public health personnel are ill-equipped to make the vital trade-offs between public health, individual health, national security, economic productivity and military preparedness. We hold neither the authority nor the political power nor the expertise to make these determinations, and should not pretend to do so.

Further, beginning in medical school, physicians are inoculated with the dictum: “Never be the first to adopt the new medical treatments nor the last to toss the old aside.” A wise-enough precept, no doubt, but problematical when faced with unprecedented perils. Preparedness requires that caution be leavened with informed, aggressive action and imagination.

Dr. Rosenstock then squeezes her grapes into sauce for a couple red herrings. She complains about “the implication that the risk now is sufficiently greater than it was before the Sept.11 attacks.” If the risk was just as high (or greater) back when she and her boss held power, why was that information kept from us? Why was action not taken?

Finally, she extols the “established public health policy that once a clear public benefit exists, taking into account known risk – as with routine childhood immunizations – then the goal is universal coverage.”

Whose goal? Yours, mine or the bureaucracy’s?

And that is the question which brings us to the larger issues.

Smallpox vaccination is voluntary, as it should be until an actual attack occurs or is imminent. People have the right to decline. But as individuals, there are times we aren’t given the right to decline immunizations we don’t want, sometimes for ourselves and most of the time for our children.

As Jane Orient, M.D., executive director of the Association of American Physicians, and Surgeons and Doctors for Disaster Preparedness points out: “Children are routinely required to take vaccines against diseases much less serious than smallpox despite comparable side effects. Public health projections estimate the number of deaths associated with administration of 300 million does of the smallpox vaccine would be 350 deaths. And yet there were 440 deaths associated with only 20 million doses of hepatitis B vaccine as of 1998.”

Finally, much of the public-health community criticism reveals a certain bureaucratic defensiveness and intellectual rigidity. As Dr. George E. Hardy, executive director of the Association of State and Territorial Health Officials, noted in a Dec. 20 Los Angeles Times news article:

As critical as it is that we be prepared to respond to a smallpox attack, it cannot come at the expense of other public health programs.

Which programs? And since when have we had only one public health program? All states have their own policies.

“Tuberculosis, E. coli and measles are not taking a furlough,” warned Patrick M. Libbey, executive director of the National Association of County and City Health Officials.

Of course not. Disease never has; it never will. But translate this statement from Dire Warning into Plain English, and in comes out: “Give us more of the taxpayers’ money.”

So what else is new?

We applaud the president for making a wise and courageous decision and sticking with it despite criticism by many (with eyes widely shut) in the public-health community.